Response to letter regarding article, "percutaneous left-ventricular support with the impella-2.5-assist device in acute cardiogenic shock results of the impella-EUROSHOCKRegistry"

Comment on Letter by Maini regarding article, "percutaneous left-ventricular support with the impella-2.5-assist device in acute cardiogenic shock: results of the impella-EUROSHOCK-registry". [Circ Heart Fail. 2013] Percutaneous left-ventricular support with the Impella-2.5-assist device in acute cardiogenic shock: results of the Impella-EUROSHOCK-registry. [Circ Heart Fail. 2013

Dreidimensionale Rekonstruktion transösophagealer zweidimensionaler Schnittbilder zur quantitativen Analyse von Vorhofseptumdefekten vom Sekundum-Typ

A non-invasive method for the determination of size and spatial relationships of the atrial septal defects to adjacent cardiac structures, which would be advantageous to those contemplating device closure, is described. The aim was to examine the value of the transesophageal threedimensional echocardiography for this purpose. Three-dimensional reconstruction of transesophageal echocardiography was performed in 17 patients. Left-to-right shunt (by oxymetrie in 16 of the 17 patients) was 2.4 to 16.2 L/min, and the QP/QS ratio was 1.4 to 4.7. The defect area of the atrail septal defect was measured throughout the whole cardiac cycle each 40 ms using two-dimensional stop frame images generated from the three-dimensional data set. Results were compared with shunt parameters by oxymetrie and with intraoperative measurements. Distances between the atrial septal defect and mitral and tricuspid annulus and the orifices of the caval and pulmonary veins were also measured. The atrial septal defect area ranged from 0.2 to 2.4 cm2 (diastole) to 0.5 to 5.6 cm2 (systole). The maximal area at end-systole was 108% of the area at the beginning of the systole, and the minimal area at end-diastole was 43%. The defect area correlated significantly with the QP/QS ratio (r = 0.7), and the maximal atrial septal defect diameters as measured by using three-dimensional echocardiography correlated well with intraoperative measurements (r = o.87). Distances to mitral and tricuspid annulus and to the superior caval vein were determined in all patients. Distances to the orifice of the inferior caval vein were measured in 12 patients, and the orifices of right pulmonary veins were visible in 5 paitents. Transesophageal three-dimensional echocardiography of atrial septal defects allows the determination of the instantaneous defect area and its dynamic changes and thus provides valuable information about the distances to adjacent cardiac structures. This may have clinical implications for the selection of patients suitable for interventional closure and for the assessment of procedural success

Percutaneous left-ventricular support with the Impella-2.5-assist device in acute cardiogenic shock: results of the Impella-EUROSHOCK-registry

Background- Acute cardiogenic shock after myocardial infarction is associated with high in-hospital mortality attributable to persisting low-cardiac output. The Impella-EUROSHOCK-registry evaluates the safety and efficacy of the Impella-2.5-percutaneous left-ventricular assist device in patients with cardiogenic shock after acute myocardial infarction. Methods and Results- This multicenter registry retrospectively included 120 patients (63.6±12.2 years; 81.7% male) with cardiogenic shock from acute myocardial infarction receiving temporary circulatory support with the Impella-2.5-percutaneous left-ventricular assist device. The primary end point evaluated mortality at 30 days. The secondary end point analyzed the change of plasma lactate after the institution of hemodynamic support, and the rate of early major adverse cardiac and cerebrovascular events as well as long-term survival. Thirty-day mortality was 64.2% in the study population. After Impella-2.5-percutaneous left-ventricular assist device implantation, lactate levels decreased from 5.8±5.0 mmol/L to 4.7±5.4 mmol/L (P=0.28) and 2.5±2.6 mmol/L (P=0.023) at 24 and 48 hours, respectively. Early major adverse cardiac and cerebrovascular events were reported in 18 (15%) patients. Major bleeding at the vascular access site, hemolysis, and pericardial tamponade occurred in 34 (28.6%), 9 (7.5%), and 2 (1.7%) patients, respectively. The parameters of age >65 and lactate level >3.8 mmol/L at admission were identified as predictors of 30-day mortality. After 317±526 days of follow-up, survival was 28.3%. Conclusions- In patients with acute cardiogenic shock from acute myocardial infarction, Impella 2.5-treatment is feasible and results in a reduction of lactate levels, suggesting improved organ perfusion. However, 30-day mortality remains high in these patients. This likely reflects the last-resort character of Impella-2.5-application in selected patients with a poor hemodynamic profile and a greater imminent risk of death. Carefully conducted randomized controlled trials are necessary to evaluate the efficacy of Impella-2.5-support in this high-risk patient group